We review standard medications given to all newborns in the nursery: ophthalmic erythromycin, hepatitis B vaccine, and vitamin K. We are joined by Stephanie Nguyen, MD, Assistant Professor of Neonatal-Perinatal Medicine at the University of Texas Southwestern Medical Center.
Dr. Neeta Goli:
Welcome to Newborn News, a podcast where we discuss educational topics for medical professionals who care for newborns. I'm your host, Dr. Neeta Goli, a pediatrician in the UT Southwestern newborn nursery.
Dr. Neeta Goli:
Welcome back to the podcast. In today's episode, we'll be talking about medications that are given in the newborn nursery. We're joined today by Dr. Stephanie Nguyen, who joined faculty in the UT Southwestern newborn nursery in 2019 after completing her residency here. Stephanie, we're so excited to have you on board and looking forward to talking to you today.
Dr. Stephanie Nguyen:
Thank you for having me.
Dr. Neeta Goli:
So like we talked about in the Newborn Nursery Basics episode, normal, healthy, term newborns do receive certain medications while they're with us in the nursery. You might've heard this referred to as the eyes and thighs. So can you remind us again what that means?
Dr. Stephanie Nguyen:
Of course, for the eyes we're talking about the ophthalmic erythromycin. For the thighs we give babies the Hepatitis B vaccine, IM Vitamin K, and here at Parkland, we do something else by also giving IM penicillin for GBS prophylaxis.
Dr. Neeta Goli:
So you might have some parents ask why healthy newborns need any medications at all. We thought we would review the rationale behind each of these medications, both for your own education and so you can better educate your families about this. So let's start with the eyes, the ophthalmic erythromycin. So this is something that we give to all newborns, ideally in the first hour of life. Can you tell me a little bit more why we do this?
Dr. Stephanie Nguyen:
So erythromycin is used to prevent neonatal conjunctivitis. Historically neonatal conjunctivitis was caused by gonorrhea, chlamydia or other viral infections. Before we used prophylaxis, 1-12% of newborns developed conjunctivitis in the first month. If they were exposed to gonorrhea or chlamydia and not treated, 35 to 50% of babies developed conjunctivitis. And this was the number one cause of neonatal blindness.
Dr. Stephanie Nguyen:
In 1881, we first used silver nitrate as prophylaxis. This treated conjunctivitis caused by both gonorrhea and chlamydia. However, some infants who received silver nitrate developed chemical conjunctivitis. Because of this risk erythromycin has been the standard of care since.
Dr. Neeta Goli:
So does the erythromycin treat gonorrhea, chlamydia or both?
Dr. Stephanie Nguyen:
Erythromycin essentially reduces gonorrhea risk by a 100%. However, it does not treat chlamydia infections, neither the conjunctivitis nor the nasopharyngeal colonization.
Dr. Neeta Goli:
So that's a really important point to understand. So if mom did have chlamydia in pregnancy, it's really important to make sure that she was treated with a negative test of cure. If not, we typically would give precautions to the mom of things to look out for in terms of chlamydial conjunctivitis and pneumonia. So now that we've explained the eyes with the erythromycin, we can move on to the thighs.
Dr. Neeta Goli:
So one of the IM injections the babies get after they're born is a Hepatitis B vaccine. So why do babies need the Hepatitis B vaccine when they're first born?
Dr. Stephanie Nguyen:
So all babies should get the Hepatitis B vaccine because it significantly reduces the risk of vertical transmission. Although all moms are tested for Hepatitis B surface antigen during pregnancy, there's still the risk of vertical transmission. If a mom is positive and the baby isn't treated the risk of vertical transmission is 30 to 85%. If mom is positive and the baby gets the first Hepatitis B vaccine, the risk significantly drops. And then if the mom is positive and the baby gets the complete Hepatitis B vaccine series, along with Hepatitis B immunoglobulin, the risk of vertical transmission drops all the way down to 1%.
Dr. Neeta Goli:
So if mom got tested in pregnancy and was negative, why does the baby need the vaccine?
Dr. Stephanie Nguyen:
There's always the chance that moms aren't identified. One, if they didn't receive adequate prenatal care, or if the lab result was misinterpreted, or it could have been a false negative. And apart from vertical transmission, there's also the risk of horizontal transmission. This can occur through saliva or open wounds and this is a more serious problem in countries where Hepatitis B is endemic.
Dr. Neeta Goli:
So since Hepatitis B isn't endemic in the US, how common is perinatally acquired Hepatitis B in the US?
Dr. Stephanie Nguyen:
For example, in 2017, there were 1000 cases of Hepatitis B transmitted perinatally in the US and then 90% of these babies go on to develop chronic Hepatitis B.
Dr. Neeta Goli:
Okay. So it sounds like even though Hepatitis B isn't endemic in the US, still an important preventive measure. When should babies get the vaccine?
Dr. Stephanie Nguyen:
It kind of depends based on size. Babies greater than two kilos should get the vaccine by 24 hours of life. If they're less than two kilos, they should get the vaccine either by a month of age, prior to discharge in the hospital, or when they reach two kilos.
Dr. Neeta Goli:
So it sounds like even if mom has been tested in pregnancy and has been found to be negative, the vaccine is a really important preventive measure that we can offer for these babies. What if you have a family who refuses the vaccine?
Dr. Stephanie Nguyen:
First off is asking them why. Helping understand their fears or reservations helps open up dialogue for us to understand each other, and then educate them and tell them the facts of where these recommendations come from so that they can better understand. If you've had your discussions and the parents are still refusing, you'll have them sign the refusal form, and then document in the medical record all of your discussions.
Dr. Neeta Goli:
Yeah. And vaccine hesitancy can be frustrating for physicians who are taking care of these patients, because vaccines have been shown to be a cornerstone of pediatrics and preventative medicine. So it can be frustrating when you have a family who's not really, we're not on the same page, but I think the literature has shown one of the most important things we can do for those families is to really just establish a relationship and keep an open mind, try to understand where they're coming from, and then we can provide education.
Dr. Stephanie Nguyen:
It's hard to, I don't know. I feel so passionate about it. So I tend to shut the conversation down with facts, but if we open up more, than hopefully parents are more receptive to it.
Dr. Neeta Goli:
Yeah. And I think, when they've done the studies have shown that, not scare tactics, but sometimes providing families with the possible effects when babies or when kids don't get vaccinated, that can sometimes, unfortunately back them into a corner a little bit more. So the only thing we can really do in this situation is just provide the information from an empathetic, nonjudgmental standpoint and let the conversation kind of flow as it is.
Dr. Stephanie Nguyen:
We do the best we can.
Dr. Neeta Goli:
Okay. So now that we've covered the Hepatitis B vaccine, let's talk a little bit more about the vitamin K. So this is a single one time dose of IM vitamin K that all babies get ideally in the first six hours of life. And we've been giving it in the US since about the 1960s. So why do babies need the vitamin K, big picture?
Dr. Stephanie Nguyen:
So if you try to recall all that step one study knowledge, vitamin K is needed for factors 2, 7, 9, and 10, along with protein C and protein S which are all important in the clotting cascade. We get vitamin K, one, from our microbiome, our gut bacteria synthesizes it, but unfortunately for newborns, their gut microbiome is not yet developed. And then two, we get vitamin K from our food sources, such as leafy green vegetables. Unfortunately, babies really only drink formula or milk. And those are not good sources. And since we can't force feed them kale, the vitamin K shot is the second best choice.
Dr. Neeta Goli:
All right. So what about, what are the risks if a baby doesn't get the vitamin K?
Dr. Stephanie Nguyen:
So the risk of vitamin K deficient bleeding happens in three forms. First is the early form that presents in the first 24 hours. This prevents as severe bleeding. And this is more due to maternal medications, such as anticonvulsants and isoniazid. The second classic form, which occurs in the first week, it's more mild bleeding, which occurs from bleeding from the umbilicus or bruising. It can happen in one in 300 kids who do not get the vitamin K shot. And then we have the late form of VKDB. This presents between two weeks and six months of age. It presents as severe bleeding, half of which the patients present with intracranial bleeding, sometimes called hemorrhagic disease of the newborn. This comes with a 20% mortality risk. Babies who don't get the vitamin K shot are 81 times higher of getting late VKDB than infants who do.
Dr. Neeta Goli:
So what if a family asks for oral vitamin K instead of the IM form?
Dr. Stephanie Nguyen:
We generally don't give the vitamin K orally because studies don't show their efficacy. It may prevent early VKDB, but the IM form is more effective at preventing late VKDB.
Dr. Neeta Goli:
So what should we know about families who refuse the vitamin K?
Dr. Stephanie Nguyen:
So in 1990, there was a study that proposed a link between IM vitamin K and childhood leukemia. There've been multiple studies that followed up and the data was re-evaluated and these findings were not confirmed. Unfortunately, some parents are still very concerned about the shot due to this original study. So much so that in 2013, there were four babies in Nashville whose parents refused the vitamin K shot. And these infants later developed late VKDB. When asked why their children did not receive the shot the parents cited fear of perceived risk of leukemia and toxins, but all families later stated that they were unaware of the risk of VKDB at all.
Dr. Stephanie Nguyen:
We need to make sure we have the discussions on the benefits of the vitamin K shot and then the risk, not only early on, but late risk of VKDB. Families who refuse vitamin K have higher rates of refusing the Hepatitis B vaccine and overall vaccine hesitancy. So if parents refuse, you can give them warnings for signs of early and classic form of VKDB. Unfortunately, late VKDB, doesn't present with early warning signs. And then make sure that they tell their pediatrician that the baby did not get the vitamin K shot and then make sure that the parents sign the vitamin K refusal form, and then document again all these discussions in the record.
Dr. Neeta Goli:
So thanks for explaining that. It sounds like there are a lot more layers to this issue. It's a little bit more complex than we might think. So I hope that now we can approach these families with a little bit more knowledge and empathy for their thought process. So now that we've talked about the eyes and two of the thighs, the Hepatitis B vaccine and vitamin K, at Parkland, there is one more medication which we give to all newborns. And that's a one-time dose of IM penicillin for GBS prophylaxis. This could be a whole episode by itself, and it will probably be an episode in the future. So we'll just review the basic protocol here.
Dr. Stephanie Nguyen:
Here at Parkland, moms are not routinely screened for GBS via the rectovaginal culture. Instead, at Parkland all babies get a one-time dose of IM penicillin, and this is to prevent early onset GBS sepsis.
Dr. Neeta Goli:
Okay. So if all babies get IM penicillin, are there still situations where moms would need the intrapartum antibiotic prophylaxis?
Dr. Stephanie Nguyen:
Yes. There are some moms who had prenatal care somewhere else earlier on in which she might have gotten the rectovaginal culture that was positive for GBS. And then, so she would be treated intrapartum, in addition to if she had a urine culture showing GBS bacteriuria during the pregnancy, if she had ruptured of membranes greater than 18 hours, if the baby's gestational age is estimated to be less than 37 weeks, if there's a history of a previous infant with invasive GBS disease, or if mom has a fever and is diagnosed with chorioamnionitis.
Dr. Neeta Goli:
So I think that covers all the medications that newborns get when they're in the well-baby nursery. Thanks so much for being here and for having this discussion with us today. As a fun way to end the episode, what is your favorite part of your workday?
Dr. Stephanie Nguyen:
Yes. Thank you for having me. And my favorite thing about my job is telling parents how cute their babies are, so that they have another avenue to gush over their cute child.
Dr. Neeta Goli:
And what parent doesn't want to do that?
Dr. Neeta Goli:
Thanks for listening to Newborn News. We hope you join us next time. If you like what you hear, make sure to subscribe and leave us a review. If you have questions, comments, feedback, or suggestions for future episodes, please email me at NewbornNews@utsouthwestern.edu. As a reminder, this content is educational and is not meant to be used as medical advice. Views or opinions expressed in this podcast are those of myself and my guests and do not necessarily reflect the views of the university.